Inappropriate Treatment of Vitamin B12 Deficiency with Folic Acid

As mentioned above, megaloblastic anemia caused by folate deficiency should not be confused with that caused by vitamin B12 deficiency. The subsequent inappropriate treatment with folic acid could have serious and frequently irreversible consequences.

Historically, before there was a clearer understanding of folate metabolism, in vitamin B12 deficiency, synthetic folic acid (Figure 3) was used in many instances to treat vitamin B12 deficiency. This at first appeared to be successful in that continued treatment with folic acid largely reversed the anemia. However, it became clear that at best this masked the underlying concomitant development of the neuropathy, and some data suggest that folic acid exacerbated the neuropathy. In any event, the inappropriate treatment of vitamin B12 with folic acid masks the emergence of the anemia. Historically, it appears that about one-third of patients with vitamin B12 deficiency present with anemia, one-third with the neuropathy, and one-third with both. In addition, the signs and symptoms associated with the anemia are easily recognizable while those of the neuropathy are less so. The earlier features of the neuropathy such as loss of balance, tingling of the fingers, and mild ataxia can easily be confused with advancing years, which coincides with the usual development of vitamin B12 deficiency. This masking of the presence of anemia in vitamin B12-deficient patients by folic acid therapy, potentially causes an early diagnosis to be missed in up to two-thirds of patients. When the vitamin B12 deficiency is eventually recognized through the onward and progressive development of the neuropathy some of the pathological features may have reached the stage at which they are irreversible.

See also: Alcohol: Disease Risk and Beneficial Effects. Anemia: Iron-Deficiency Anemia. Cobalamins. Celiac Disease. Folic Acid.

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